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Medicines and Falls – Guidance on Causes and Risks
(Version 1 – July 2015)
All patients should have their drug burden reviewed with respect to its propensity to cause falls.
The history should establish the reason the drug was given, when it started, whether it is effective and
what its side effects have been.
An attempt should be made to reduce the number and dosage of medications, where possible.
Ensure they are appropriate and not causing undue side effects.
Falls can be caused by almost any drug that acts on the brain or on the circulation. Usually the
mechanism leading to a fall is one or more of:
• sedation, with slowing of reaction times and impaired balance
• hypotension, including orthostatic (postural) hypotension
• bradycardia, tachycardia or periods of asystole
Falls may be the consequence of recent medication changes, but are usually caused by medicines that
have been given for some time.
Red:
Amber:
Yellow:
High risk: can commonly cause falls alone or in combination
Moderate risk: can cause falls, especially in combination
Lower risk: can possibly causes falls, particularly in combination
Drugs acting on the brain (aka psychotropic drugs)
There is good evidence that stopping these drugs can reduce falls (1).
Taking such a medicine roughly doubles the risk of falling. There are no data on the effect of taking two
or more such medicines at the same time. (2)
Sedatives, antipsychotics and sedating antidepressants cause drowsiness and slow reaction times.
Some antidepressants and antipsychotics also cause orthostatic hypotension.
DRUG CLASS
EXAMPLES
EFFECT
Sedatives: Benzodiazepines
Chlordiazepoxide, clonazepam,
diazepam, lorazepam,
nitrazepam, oxazepam,
temazepam
Drowsiness, slow reactions,
impaired balance.
Caution in patients who have
been taking them long term.
Sedatives: Z-Drugs
Zaleplon, zopiclone, zolpidem
Drowsiness, slow reactions,
impaired balance.
Sedating antidepressants
(tricyclics and related
drugs)
Amitriptyline, clomipramine,
dosulepin, doxepin, imipramine,
lofepramine, nortriptyline,
trimipramine
All have some alpha-receptor
blocking activity and can cause
orthostatic hypotension.
All are also histamine-H2
blockers and cause drowsiness,
impaired balance and slow
reaction times.
Mianserin, mirtazapine,
trazodone
Monoamine Oxidase Inhibitors
Isocarboxazid, phenelzine,
tranylcypromine
Now seldom used. All (except
moclobemide) can cause severe
orthostatic hypotension.
SSRI antidepressants
Citalopram, escitalopram,
fluoxetine, paroxetine, sertraline
In population studies, cause falls
as much as other
antidepressants.
(See below).
Several population studies have shown that SSRIs are consistently associated with an increased
rate of falls and fractures, but there are no prospective trials. The mechanism of such an effect is
unknown. They cause orthostatic hypotension and bradycardia but only rarely as an idiosyncratic
side effect. They do not normally sedate but can impair sleep quality.
SNRI antidepressants
Duloxetine, venlafaxine
As for SSRIs but also commonly
cause orthostatic
hypotension.
Drugs for psychosis and
related conditions
Chlorpromazine, fluphenazine,
haloperidol, olanzapine,
quetiapine, risperidone,
trifluoperazine
All have some alpha-receptor
blocking activity and can cause
orthostatic hypotension.
Sedation, slow reflexes, loss of
balance.
Opiate (and opioid) analgesics
Codeine, dihydrocodeine,
fentanyl, morphine, oxycodone,
tramadol
Drowsiness, slow reactions,
impair balance, cause delirium,
Anti-convulsants
Phenytoin
May cause permanent cerebellar
damage and unsteadiness in
long term use at therapeutic
dose.
Excess blood levels cause
unsteadiness and ataxia.
Anti-convulsants
Carbamazepine, phenobarbital
Drowsiness, slow reactions.
Excess blood levels cause
unsteadiness and ataxia.
Anti-convulsants
Gabapentin, sodium valproate
Some data suggest an
association with falls.
Anti-convulsants
Lamotrigine, levatiracetam,
pregabalin, topiramate
Insufficient data to know if these
newer agents cause falls, but it
appears less likely
Parkinson’s disease:
Dopamine agonists
Pramipexole, ropinirole
Can cause orthostatic
hypotension and delirium.
(See below)
Parkinson’s disease:
MAOI-B inhibitors
Selegiline
Causes orthostatic hypotension.
(See below).
The association between drugs for Parkinson’s disease and falls is difficult to quantify as
orthostatic hypotension is part of the disease state and falls are common. In general only if
orthostatic hypotension is definitely considered drug-related should medication be changed.
Anti-muscarinics
Orphenadrine, procyclidine,
trihexyphenidyl
Dizziness, blurred vision,
confusion.
Anti-dementia drugs:
AChEIs
Donepezil, galantamine,
rivastigmine
Dizziness, bradycardia, syncope,
muscle spasm.
Anti-dementia drugs:
Memantine
Muscle relaxants
Memantine
Commonly causes dizziness and
balance disorders
Drowsiness, reduced muscle
tone. (See below).
Baclofen, dantrolene
There are little falls data on muscle relaxants as they tend to be used in conditions associated
with falls.
Vestibular sedatives / antiemetics
Phenothiazines
Cyclizine, metoclopramide,
prochlorperazine
Some alpha-receptor blocking
activity and can cause
orthostatic hypotension.
Sedation, slow reflexes, loss of
balance.
Vestibular sedatives
Antihistamines
Betahistine, cinnarazine
No data, but sedation likely to
contribute to falls.
Antihistamines for allergy
(Sedating)
Chlophenamine, hydroxyzine,
promethazine, trimeprazine
No data, but sedation likely to
contribute to falls.
Anticholinergics acting on the
bladder
Oxybutinin, solifenacin,
tolterodine
No data, but have known CNS
effects.
Drugs acting on the heart and circulation
Maintaining consciousness and an upright posture requires adequate blood flow to the brain. This
requires adequate pulse and blood pressure. In older people a systolic BP of 110mmHg or less is
associated with an increased risk of falls.
Any drug that reduces blood pressure or slows the heart can cause falls (or feeling faint or loss of
consciousness or “legs giving way”) (3). In some patients the cause is clear – they may be
hypotensive, or have a systolic blood pressure drop on standing. Others may have a normal blood
pressure lying and standing, but have syncope or pre-syncope from underlying circulatory disorders.
Alpha receptor blockers
(Used for hypertension or for
prostatism in men).
Alfluzosin, doxazosin, indoramin, Commonly cause severe
prazosin, tamsulosin, terazocin
orthostatic hypotension.
Centrally acting alpha-2
receptor agonists
Clonidine, moxonidine
Can cause severe orthostatic
hypotension. Sedating.
Thiazide diuretics
Bendroflumethiazide,
chlorthalidone, metolazone
Cause orthostatic hypotension.
Muscle weakness due to
lowered sodium and potassium
plasma levels.
Loop diuretics
Bumetanide, furosemide
Dehydration causes
hypotension.
Muscle weakness due to
lowered sodium and potassium
plasma levels.
Angiotensin converting
enzyme inhibitors (ACEIs)
Captopril, enalapril, lisinopril,
perindopril, ramipril
Can cause severe orthostatic
hypotension.
Symptomatic hypotension in systolic cardiac failure
 ACEIs and beta blockers have a survival benefit in systolic cardiac failure and should be
maintained whenever possible.
 NICE recommends: stop nitrates, calcium channel blockers and other vasodilators. If no
evidence of cardiac congestion, reduce diuretics. If problem persists, seek specialist
advice.
 The mortality risk from a fall at age 85 is about 1% per fall. The frequency of falls
determines the balance between risk and benefit.
 Most cardiac failure in older people is diastolic (preserved left ventricular function). ACEIs
and beta blockers have little survival benefit in diastolic failure.
Angiotensin receptor
blockers (ARBs)
Candesartan, irbesartan,
losartan, telmesartan, valsartan
Cause less orthostatic
hypotension than ACEIs but still
carry significant risk.
Beta blockers
Atenolol, bisoprolol, propranolol,
sotalol
Can cause bradycardia and
hypotension.
Anti-anginals
Glyceryl trinitrate (GTN)
Commonly cause syncope due
to sudden blood pressure drop.
Isosorbide dinitrate/mononitrate,
nicorandil
Cause hypotension and
paroxysmal hypotension
Calcium channel blockers that
only reduce blood pressure
Amlodipine, felodipine,
lercanidipine, nifedipine
Cause hypotension and
paroxysmal hypotension
Calcium channel blockers
which reduce blood pressure
and slow the pulse
Diltiazem, verapamil
Can cause hypotension and/or
bradycardia
Other antidysrhythmics
Amiodarone, digoxin, flecainide
Can cause bradycardia and
other arrhythmias.
Data on digoxin and falls
probably spurious due to
confounding by indication.
Author:
Jed Hewitt
Chief Pharmacist – Governance & Professional Practice
Based on a document produced by The John Radcliffe Hospital, Oxford (2011).
Approved by the Trust Drugs & Therapeutics Group: July 2015
Date of next review: July 2018
References:
1) Campbell, Robertson et al. J. Am. Geriatric Soc 1999: 47: 850-3
2) Darowski, Chambers & Chambers. Drugs & Aging 2009; 26 (5): 381-395
3) Darowski & Whiting. Reviews in Clinical Gerontology 2011; 21 (2): 170-179
4) Van der Velde et al. J. Am. Geriatric Soc 2007; 55: 734-739
5) Alsop & MacMahon. Postgrad MJ 2001; 77: 403-5